What is considered appropriate staffing for grads off of orientation.

[kimmicoobug]

I have nothing to compare here so I wanted to get opinions from those wiser than I. I have been off of orienation for about three weeks. I felt my orientation was ok. I had an orientation that lasted three months on three different units. I feel that I did learn alot, but have a long way to go in regards to med-surg. During orientation, I oriented to easy patients. I feel this was a good start due to time management as a new nurse. I could take six or seven and still leave on time (night shift) BUT, now orientation is over and I am completely overwhelmed.

Last night, for example, I was ready to quit because I felt so discouraged. I had a patient dying of cancer (so was worried about him passing on my shift), another with respiratory issues with unstable sats, one with uncontrolled blood pressures, and one who couldn't empty his bladder with nearly 2000 cc urine, and a temp with an MD who didn't want to do anything about it (ended up calling on-call doc at 0130). Then this morning, one of my patients went downhill and I was so clueless that I didn't catch it! I was so wrapped up in getting paperwork done and focusing on her uncontrolled BP's that I didn't realize she was desating and developing resp issues. The day shift RT was the one who caught it and within an hour she was sent to ICU. Oh, and on top of that, I made a lovely little med error:( that just made me feel like Sh1t. And I got to fill out an incident report.

So, I came home and realized how unsafe I am d/t my inexperience and am wondering if this is normal staffing for us new ones. I was given what is considered the "front load" of 6. The load that needs close observance and is usually the higher acuity load. On top of this, my CNA was an OB nurse who I had to ask several times to do things that CNA's on my floor do and then she took an hour break and got called back so was stuck with no CNA for over an hour and a half. (Oh, and I am not dishing dirt on this nurse because I have worked with her several times in OB and if I were in trouble with a labor, I would want her for my nurse...oh yeah, I am also cross trained to OB and appear to be the unofficial float to OB from med-surg. I love OB and hope to be an OB nurse one day and enjoy floating there. My only complaint about this is that when I float, I lose my patient group and have to pick up another group when I come back.)

OK, so back to the story. Is this typical? Are other hospitals expecting us new nurses to take higher acuity right off the bat off of orientation or do they give you a bit of cushion.. you know easier groups with one or two high acuity patients thrown in for good measure. I think that I will make a good nurse someday, but right now I am just barely hanging in there. I am even wondering if this is a good place to work as a new nurse of three months. But, if this is typical then I will stay where I am at.

I don't want to be a quitter if I don't have to be.

So, any words you all can give me. Anything is much needed at this point.

[cannoli]

It has nothing to do with the type of education or training one has had.

What it has to do with is the intolerable, heavy, unsafe work load that exists in most hospitals in the United States, things may be different elsewhere in the world.

With the nurse patient ratios what they are and the acuity of the patients (and assignments are done by numbers not acuity) it is impossible to get the work done in the time allowed, God forbid if there should be an emergency.

Sometimes the acuity is so high, all the nurses on the floor are in the same boat.

Some charge nurses are receptive and helpful others are not, you may as well talk to the wall. You can refuse an assignment before taking report and be threatened that you will never work in the hospital system again and also be threatened with being reported to the BON for patient abandonment.

It's easy to say refuse an assignment, it's not always so easily done, and sometimes there is just no other body to be had from anywhere, the agency or anywhere else.

I also think if you are young and single it's a lot easier to walk off, then for someone say that has a wife and family, or a single mother, there are consequences that maybe they can't afford to take.

It's so easy to say just refuse, and I bet the majority of the people that say it have never done it.

To the original poster, hang in there, it will get better, and it is still overwhelming to veterans just because of the sheer numbers and acuity. What you might have missed on a patient, you learned from it and you won't miss it again, you will know what you are seeing next time and you will know what to do.

Get some nursing Liability Insurance if you don't already have it, and keep the same policy renewed from year to year.

Keep the faith, and good luck.

[Teshiee]

Sounds like you got a bad list of high acuity patients even if the ratio is 6 if you have 2 patients that can potentially code it makes the list like 10-12. I feel ya you had no support what so ever! Unfortunately when you are off orientation you are one of the staff. I am sorry you had a bad night. Express your concerns to your supervisor sometimes you have to watch how some of these nurses justify staffing their patients. They do this mess in my unit lower the acuity when it is not warranted so they can justify in giving you an extra paitent. When in doubt SHOUT!!!!! You do not have to accept an assignment that is dangerous! You worked very hard for your license. :-)

[jnette, ASN, EMT-I]

I hear you , Kimmiekoo !

I'm pretty much in the same boat... new grad, and while dialysis is my primary, I just started orientation at another hospital on medsurge for some prn. I asked the other new grads there what their orientation time was... get this ! They all receive a full 120 hours.. no, not a typo... not 120 DAYS, but 120 HOURS !!! Then they're thrown to the wolves. Assignments are anywhere from 6-8 pts., or more, depending on what's going on. I feel lucky that I'm getting 4 weeks orientation.

It really IS a scary feeling as there are so many dx., etc. that I don't deal with on a regular basis in dialysis, and everything you learned in the books seems to somehow just float away. One of the reasons I chose to do prn M/S... to refresh these skills and bring back to life what I had learned. I just hope that when I'm "set loose", that I can ask for input from the other nurses.. just INPUT on how best to approach difficult scenarios... that would be a great help in itself.

I wish you the best... keep posting, 'cuz I learn so much from reading here... one way we can help each other ! Hang in there !

:)

[rn-jane]

hang in there!

You seem to me that you take your nursing seriously and are committed to your patients. Don't take it to heart, you had a bad night, we all have them, but where were the senior nurses and the charge nurse when you're patient was going bad.

i'm a charge nurse and a preceptor and with my new grads i try to watch very carefully and try to mentor as time progresses. They are there to help you, when a patient on my floor goes bad (it's a collaborative team effort to get the patient to where they need to be.)

Sometimes the assignment is not fair, instead of looking at acuities, sometimes mgmt only looks at the numbers. A term lately i'm tired of hearing from the upper mgmt.

goodluck and welcome to nursing!!!!!!!!

[KailuaNurse]

At the facility I work for, after orientation, they usually try to give new grads relatively easy assignments. Usually one or two busy kids and two easier kids (four is the usual assignment). We also have a Resource Nurse on staff besides the charge nurse. This resource nurse is just for the medical unit, and is available for any nurse to ask a question, or just ask for help if their assignment is really busy. That extra person floating around is a really big help.

[susanmary]

3rd Shift Guy -- excellent post. Kimmi -- I think it's great that you had a 3 month-long orientation. By the end of that time, you should have been carrying a full assignment of varying acuity so that you would have been better prepared for the high acuity/challenges that med/surg brings. After orientation, you should expect to get an assignment that is consistent with your floor's acuity. Even with the best intentions by the charge nurse, at times you will not receive a "fair" assignment -- you need to advocate for yourself.

Have you considered working on days for awhile for the learning experiences? Might be helpful to you. In reality, you should not have been assigned 6 patients with the highest acuity. Could you have negotiated a "switch" during your shift with another nurse for a more stable patient.

Reread your initial post. In retrospect, would you have prioritized your assignment differently (if at all.) Were your patients trending downward during previous shifts, or were they experiencing acute issues? (By quickly surveying the vitals, i/o's for the past shift or two -- you'd be surprised how much trending you WILL find.)

How did you address the patient with respiratory issues with unstable sats? Did you call a respiratory therapist, doctor to address this & how did the patient respond to any interventions? Why was your patient's urinary retention not addressed by the previous shift? When was the last time the patient voided/straight cathed, etc? Why was the patient retaining 2000 cc of urine? Was the patient ultimately cathed?

You are incorporating so much into your nursing practice already. Just be good to yourself, continue to advocate for yourself, & do the best you can. Don't berate yourself over mistakes -- learn from them. When you are feeling overwhelmed at work, step back -- take a deep breathe -- and prioritize (and reprioritize as needed.) You sound like a wonderful person and great nurse. Give it some time .... and always follow your heart and what makes you happy.

:)